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Electives - Family Medicine

Integrated Behavioral Health in Primary Care

Elective Number: 1410 (lottery)

Rotation Supervisors: Claudia Allen, Ph.D. (434) 924-1622

Designated Signer: Wanda Hudson (434) 924-1609

Duration: 2 weeks (only in R6a, 9b & 13a) - otherwise 4 weeks

Available: Rotations 1-5, 6a, 7, 8, 9b, 10-12, 13a & 14

Report to: Dr. Allen

Time to Report: 9:00 am

Place to Report: Room 1067 Primary Care Center 1st floor in FM outpatient clinic

Typical day: 9:00 am - 5:00 pm

Attendance: Attendance at elective activities is mandatory.

  • Anyone who is ill or has a personal or family emergency must contact Student Affairs and the Attending on Service.
  • Students are allowed to take off up to 1 day per week to interview between November 1 and February 1.
    • Specific days missed must be approved by the Attending on Service.

Number of students per rotation:

Course Description:

Objectives:
1. Provide the student with experience delivering integrated behavioral health care in a primary care setting on an interdisciplinary health care team.
2. Offer the student the opportunity to begin to master several brief behavioral interventions suitable for a physician to use when addressing psychological or behavior change issues in a medical office visit.
3. Augment the student’s fund of knowledge about normative child and family development, as well as the diagnosis and treatment of psychological problems frequently seen in the primary care setting.
4. Increase the student’s mastery of the communication, self-awareness and professional skills essential to a strong therapeutic alliance between doctor and patient.
5. Enhance the student’s understanding of the mind-body connection and expose him or her to a multidisciplinary, biopsychosocial approach to patient-centered care within an interprofessional learning environment.
6. Increase the student’s sensitivity to cultural differences that may impact health and methods of intervention.

Activities:
1. On their first day, medical students meet with Dr. Allen for orientation to the elective and discussion of their particular interests. They are assigned several core readings and additional readings based on their interests. Core readings include The Fifteen Minute Hour: Therapeutic Talk in Primary Care, by Stuart and Lieberman; Two Minute Talks to Improve Psychological and Behavioral Health, by Clabby, which discusses very brief psychosocial interventions in primary care, and Competence, Courage and Change, by Waters and Lawrence, which outlines the strength-based family therapy orientation of the clinic.

2. The student participates in the live therapy team that staffs psychotherapy cases behind a one-way mirror two half days a week. The team is made up of a PhD level faculty member, 3 graduate students in clinical psychology, a Family Medicine resident, and on certain days Psychiatry resident. Medical students most often observe and participate in the discussion, but sometimes are offered the opportunity to conduct a session themselves, especially on the four week rotation. If a student does conduct a session, he or she drafts the note for the medical record, which is edited and entered by the faculty member.

3. The student also observes an additional three half days a week when fourth year doctoral students in clinical psychology conduct psychotherapy behind the mirror. The graduate student therapist discusses the case with the medical student before and after each session, and during a break in the session. The medical student also sits in during the graduate student therapist’s supervision with the faculty member of these cases.


4. The student accompanies the graduate student therapist three half days a week when the graduate student provides integrated mental health services in the Primary Care Clinic. Initially the medical student shadows the graduate student as he or she provides immediate behavioral interventions to patients being seen in the FM PCC. These services include brief psychological assessment and referral, safety screening, motivational interviewing, relaxation training, child development screenings (ASQ and M-CHAT) and developing non-pharmacological treatment plans for our patients with chronic pain. After observing a few and discussing them, the medical student can apply some of these interventions him or herself and draft the accompanying EMR note. Medical students also have the opportunity to assist with follow-up telephone calls to these patients to check on their progress.

5. The student accompanies the graduate student therapist or faculty member on Collaborative Care calls, where a physician requests an immediate consultation regarding a patient currently being seen in an outpatient or inpatient hospital service. These collaborative care calls may involve brief psychological assessment, safety screening, behavior change intervention, non-pharmacological pain management, or child development consultation. Medical students are encouraged to train to conduct one or more collaborative care interventions themselves under the supervision of the PhD attendings.


6. With the assistance of one of the faculty, medical students on the four week rotation choose an independent project. Recent examples have included following up with patients on our waiting list to ascertain their status and needs; developing a list of substance abuse resources; developing a presentation; co-leading a behavioral rounds.


7. The student attends Behavioral Rounds and Wellness Activities of the week, which are part of the Family Medicine resident conference series on Tuesday afternoons. Students also have the option of attending the rest of the Tuesday afternoon Family Medicine conferences, although most prefer to observe psychotherapy cases behind the mirror during that time.

8. The student completes a Patient Centered Communication module, which involves on line training about communication and live observations of providers.


Assessment:
Faculty complete evaluations of each student at the end of the rotation. Students are evaluated on the basis of their level of engagement and communication skills, as well as fund of knowledge. It is assumed that most students’ fund of knowledge about psychosocial problems and treatments will be at the novice level. If they conduct patient interviews themselves, or have patient contact by phone, they are given feedback on their communication skills, professionalism, and fund of knowledge. If they complete an independent project, they are also given feedback on the content of the project, level of independence, and quality of presentation.

Daily Schedule: general hours 8:30-5:30

Monday
Morning: Shadow staff therapist in PCC precepting room; participate in brief interventions
Afternoon: observe staff therapist behind two way mirror; take collaborative care calls with staff therapist and eventually on own.

Tuesday
Morning: Shadow staff therapist in PCC precepting room; participate in brief interventions
Afternoon: resident conferences in 3N (starting with Grand Rounds (lunch provided) at 12:30)

Wednesday
Morning: cover phone/pager in Family Stress Clinic office; respond to collaborative care calls with assistance of faculty; work on reading and independent project
Afternoon: participate in live therapy team behind two way mirror

Thursday
Morning: cover phone/pager in Family Stress Clinic office; respond to collaborative care calls with assistance of faculty; work on reading and independent project
Afternoon: participate in live therapy team behind two way mirror

Friday
Morning: Shadow staff therapist in PCC precepting room; participate in brief interventions
Afternoon: observe staff therapist behind two way mirror; take collaborative care calls with staff therapist and eventually on own.